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Swift has recently suggested that acute articular rheumatism is a manifestation of allergy. It has long been known that there is a relationship between tonsillitis and the joint infection. With the allergic conception this seems satisfactorily explained.
When the primary infection is in the tonsils, the streptococci and the protein derived from them gain access to the blood stream; and, in the same manner as in tuberculosis, the body cells are rendered sensitive to streptococci and their products.
There are certain tissues which streptococci are prone to infect, among which are the heart valves and joint structures. These localizations are probably selective, the same as the tonsils are the location of choice in the primary streptococcus infection and in diphtheria; and Peyer’s patches in typhoid fever.
Streptococci may escape from the tonsillar infection and circulate in the blood in small quantities, the same as tubercle bacilli, without producing illness. But let them become implanted in a joint or in the heart valves and an immediate reaction occurs, differing according to the nature of the tissues in the two situations. In both instances the cells have been sensitized by the circulating streptococcus protein. In the former the allergic reaction shows as a predominantly exudative process which later may become predominantly proliferative or may disappear by absorption of the exudate. Large quantities of serum may be poured out in the joint just as large effusions occur in the pleura when it is the seat of an allergic reaction in tuberculosis. In the heart valve, on the other hand, the tissues are dense and the reaction, while inflammatory, shows a preponderance of proliferation and a minimum of exudation. The after course of the infection will depend on its severity and upon whether or not the allergic reaction is kept up for a period of time by further quantities of streptococci and streptococcal products gaining access to the blood stream and coming in contact with the joint or valvular tissues. Where the tonsils are furnishing the source of repeated reinoculations, immediate tonsillectomy should relieve the exacerbations, unless further reinoculation is caused by the trauma of the operation. Owing to the fact that there is great danger of reinoculations following tonsillectomy during acute inflammation, it is a very questionable procedure, however, and should be done only after most careful consideration. If no new exacerbations are taking place, the removal of the tonsils can await recovery of the joint.